Modules

This module allows access to a multidisciplinary case history created from the notes recorded manually by the doctors and staff, and from other sources recorded automatically from its data exchange with other modules in the application.

Description of functions:

• Manually records the notes considered to be part of a case history, with options such as: font type, letter size, tabs, copy/paste, etc.
• Allows a particular report to be attached (image, scanned document).
• The System associates the entry with the treatment the patient is currently receiving.
• It also automatically feeds from the information exchanged with other modules.
• Notes may be viewed by: Treatment, Service, Note type, Type of Case History, etc.
• It is possible to choose the number of notes to be viewed or to select a period between two dates.
• Under certain circumstances, a note may be modified or cancelled.

Provides access to all the documents associated with a medical record, classified according to their type.

Description of functions:

• It uses all the SISinf-GesDoc programme functions.
• It allows users with certain privileges to define Word templates the doctors can use to create their reports.
• Each template is associated with a report “Type” and “Model”, making their classification simpler.
• It is possible to specify the number of reports needed.
• After selecting the report to be prepared and having specified the patient and the kind of treatment to be given, the chosen template opens up, automatically filling in all the information that can be obtained from the database.
• The report will be visible to the rest of the staff once it has been closed.
• Once the report has been created it is possible to: View, Modify, Close, Delete, Clone and Edit it.

Allows additional data corresponding to a patient and/or treatment not recorded through the various management applications to be captured and used.

Description of functions:

• By using a tool designed for the task, data sheets can be defined and created.
• The Assessment is defined by “Type” and “Model”, making its classification simpler.
• Assessments that may change over time may also be defined.
• Once all the data for the assessment has been recorded, it is possible to calculate a specific value (Barthel calculation, etc.).
• Each model contains headings to identify the treatment and the patient, and others which contain the assessment details which may be grouped into data blocks made up of a set of data.

A Study associates a patient’s medical record with information not contained on the database, but is however, located in the system (images, x-rays, electrocardiograms, spirometries, scanned documents, etc.)

Description of functions:

• A Study link a patient with the health care received.
• The specific type of study is selected from a list, and may be identified with a description if desired.
• The browser allows you to select the file containing the study.
• Any file format is permitted.
• Once created, a study may be viewed, modified or deleted.

All health problems and diagnoses are recorded on the patient’s file which, due to their seriousness or chronic nature, are considered to merit highlighting on his or her medical record.

Description of functions:

• In order to assign a health problem to a patient, one of the problems listed should be selected, and optionally, a diagnosis may also be made.
• When a health problem no longer exists, it can be marked as inactive.
• It is possible to view any patient’s health problems. All the active health problems are shown by default, but it also provides access to the patient’s medical history.

This aids dialogue between the various doctors and staff concerning a patient’s illness.

Description of functions:

• A Consultation may be made with a Service or with a particular Doctor, by providing information about the diagnosis and about the questions one wishes to ask.
• A Consultation is assigned to the doctor who answers it. The doctor may answer it or pass it on to another person.
• All medical consultations are recorded on the patient’s record.

Allows medical instructions to be recorded and the medication sheet to be accessed, and offers the member of the medical staff a set of directions and warnings, which considerably improves the prescription quality.

Description of functions:

Medical Instructions Module
• Defines the MI for Hospital Treatment, Outpatients and Emergencies.
• The MI for Outpatients allows more than one MI to be defined per Service.
• Retrieval of the MI from other treatments.
• Establishes medication based on Guidelines, outside Guidelines and for Outpatients.
• Access to medication through: Name (Brand or main active ingredient) or Therapeutic Classification.
• Control of interaction between different medicines.
• By default, Dose, Frequency and Method or with a list of permitted quantities
• Marks days to be excluded.
• Sporadic doses.
• Marks the alterations made by the doctor for specific periods.
• For Outpatient Medical Instructions: marks the prescription medication to be administered by the patient.
• Variable directions by date, in order to control specific medication (E.g. Sintrom).
• IM printout.
• Option to provide comments: doctor, nursing staff or Pharmacy.
• Screen of patients pending verification by Pharmacy.
• Screen of patients pending viewing by Nursing Staff.
• View of discontinued medication.
• IM record.
• Definition of Medical Instructions protocols.

Medication Administration Sheet Module
• Displays the Administration Sheet by times, with details of the medication to be given to the patient.
• Possibility of administering extra medication.

Allows the member of staff from their own workstation to request visits, examinations, or additional tests for their patients.

Description of functions:

• Access to the patient may be gained through the doctor’s surgery agenda, the Hospital Admissions census or Emergencies.
• It allows visits, tests or additional examinations to be requested.
• The tests are accessed through the hospital’s own catalogue, through templates displaying a list of the most common tests.
• The tests often requested together may be grouped together in profiles.
• Once the petition has been approved, it is transferred to the Hospitals IS where the request is then processed.
• When a petition is formulated, a signal is activated on the census on which the patient appears indicating that the tests have been requested.

This incorporates a patient’s Living Will into his or her electronic medical record.

Description of functions:

• In the presence of the patient, the user may create the Living Will or, if the patient has brought it to the clinic, it can be scanned into the system.
• This document replaces any other existing document.
• On a Medical Record to which a Living Will is attached, a signal will indicate this fact, and may be viewed whenever the Record is opened.

Allows the recording of measurements that are considered necessary to enable the patients’ clinical evolution to be monitored.

Description of functions:

• Allows the vital signs of interest to the hospital to be defined.
• When defining the vital sign, the description, maximum and minimum values and unit of measurement, must be defined, and diagrams, and cumulative or individual values may also be added.
• The measurements of one or several vital signs may be viewed either graphically or as data.
• This application may be consulted when administering treatment or for the medical record.

To record any medical history considered to be relevant and include it on the patient’s medical record.

Description of functions:

• To add a patient's medical history, select from a previously defined list, providing a description of the history to complete the information.
• Once this record has been entered it becomes part of the patient’s medical record.
• It is possible to view the medical history in the order established by priority.
• An item of medical history may be deleted, but it will continue to be linked to the patient’s medical record.
• The active items forming part of the medical history will be displayed in order of priority as established by the doctor, but they may also be displayed in chronological order.

To record any allergies considered of relevance and include them on the patient’s medical record.

Description of functions:

• To add a patient’s allergy, select from a previously defined list, providing a description of the allergy to complete the information.
• Once this record has been entered it becomes part of the patient’s medical record.
• Once recorded, if the Hospital’s Pharmacy IS is adapted for this function, it can be handled in the Medical Instructions register, allowing any incompatibilities to be detected.
• An allergy may be deleted, but it will continue to be linked to the patient’s medical history.
• The allergies will be displayed in order of priority as established by the doctor, but they may also be displayed in chronological order.

Provides an overall view of the data considered to be of greatest importance, when the medical record is displayed.

Description of functions:

• It simplifies and optimises the overall summary of the patient’s details.
• It is not necessary to navigate through the entire patient’s record to access this summary view.
• Users with administrative powers can configure the template to show the basic information modules and their distribution on the screen.
• The basic template may be customised, to offer a different view depending on requirements of the Service or the individual doctor.